Co-management of elderly orthopaedic patients with a geriatrician has been shown to decrease inpatient length of stay and patient complications

1. P A R T N E R S O R T H O P A E D I C
Trauma Rounds
Case Reports from the Mass General Hospital and Brigham & Women’s Hospital
A Quarterly Case Study Volume 4, Winter 2013
Geriatric Fracture Patient Co-management
Michael J Weaver, MD
In the United States, hip fractures represent a
significant medical burden. The annual cost of
caring for geriatric patients with hip fractures is
$10 - 15 billion. As the Baby Boomer generation
continues to age, the number of patients with
hip fractures is expected to rise dramatically.
The rate of mortality at one year in this patient population runs
between 12 and 37% (1).
Co-management of elderly orthopaedic patients with a geriatri-
cian has been shown to decrease inpatient length of stay and
patient complications (2). At our two institutions, our ortho-
paedic and geriatric medicine services have collaborated to
form a combined service. We have found that this ortho- Figure 1: Geriatric patient care is optimized by a multi-disciplinary
geriatric service improves patient care, reduces inpatient length team approach.
of stay, and improves patient and family satisfaction. hours of admission. The risks of complication are minimized
Optimal treatment of geriatric patients requires a holistic ap- when we operate within 24 to 48 hours of a patient’s admission.
proach with multiple specialists caring for the patient. Patients Post-operative medication and fluid management are critical.
are co-managed by an orthopaedic surgeon and a geriatrician Pain control is also very important, with appropriate dosing of
throughout their hospitalization (Figure 1). Medications and narcotic medication, use of blocks and other regional forms of
pain control are optimized to avoid delirium. Nutritionists are anesthesia necessary to avoid delirium.
involved to maximize metabolic status. Endocrinologists are We recently reviewed the effects of instituting the ortho-
consulted to assess for osteoporosis, evaluate vitamin D defi- geriatric services and found that we have reduced length of stay
ciency and to provide advice for reducing the risk of future frac- by 1.6 days. In a meta-analysis performed by our geriatric
ture. Physical therapy plays an integral role in getting patients group, we documented a decrease in 30-day and 1-year mortal-
out of bed and working on fall prevention. By taking this ity when geriatric hip fracture patients are treated by similar
multi-disciplinary approach we improve patient outcomes. combined services (3).
Combined Geriatric Service Endocrine Consultation
Patients with fragility fractures admitted to our two institutions Hip fractures in the elderly are typically fragility fractures and
are co-managed by our ortho-geriatric service and are seen are often associated with osteoporosis. At our institutions, we
daily by both their orthopaedic surgeon and geriatrician. partner with an endocrinologist to ensure that the appropriate
Our geriatricians perform a thorough pre-operative assessment work-up is performed and any metabolic deficiencies or osteo-
including a cognitive evaluation. Medications are optimized, porosis are addressed while the patient is an inpatient.
with patients stratified based on risk. It is particularly impor- Vitamin D deficiency is commonplace – particularly here in
tant to avoid delirium-causing medication such as anticholiner- New England – thus, vitamin D levels should be obtained dur-
gics. We work closely with our colleagues in Anesthesia to en- ing the pre-operative work-up. All patients should be on cal-
sure that patients are cleared expeditiously so that their fracture cium and vitamin D supplementation during their hospitaliza-
can be addressed. We strive to take patients to the OR within 24 tion and at discharge.
Trauma Rounds, Volume 4, Winter 2013
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2. P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S
Bone density testing should be performed after the patient is
discharged from the hospital, particularly if the results are not
recent. When bone mineral density is low, bisphosphonate
therapy is useful and has been shown to reduce the risk of fur-
ther fracture. Care should be taken to avoid use of bisphos-
phonates for more than 5-years as long-term use may be related
to atypical femoral fractures (4). Teriparatide (Forteo) may be
useful for recalcitrant cases.
Surgical Challenges
Geriatric fractures can be challenging. Poor bone quality and
previous surgeries can limit fixation options and make surgery
difficult.
Femoral Neck Fractures (Total hip arthroplasty (THA) vs. hemiarthro-
plasty): Many of our geriatric patients lead active lifestyles. THA
provides a higher level of pain relief and improve function when Figure 2: 78F with a previous cemented long stemmed total knee
compared with hemiarthroplasty. However, THA exposes pa- replacement. She now presents with subtrochanteric femur fracture
tients to a longer surgery with a higher blood loss and increases a (left). The cemented stem precludes intramedullary fixation which
patient’s risk of dislocation. Relative contra-indications to THA would be the standard treatment for this fracture pattern. Instead she
include neuromuscular disorders like Parkinson’s disease, diffi- is treated with open reduction and fixation with a 95 degree blade
plate (right). The tip of the stem is spanned by the plate to avoid a
culty or inability to adhere to hip precautions and advanced age. stress riser effect.
In both operations I avoid the use of taper type stems as these act
as wedges, increase hoop stresses, and can lead to periprosthetic Summary
fractures in patients with poor bone quality. When bone quality Geriatric fractures are best managed with a multidisciplinary
is compromised, cement fixation provides immediate stability for approach. Bringing together orthopaedic surgeons, geriatri-
the femoral prosthesis and reduces the risk of periprosthetic frac- cians, anesthesiologists, endocrinologists, nurses, therapists and
ture. nutritionists improves patient care and optimizes outcomes.
Peritrochanteric Hip Fractures (Cephalomedullary Nail vs. Sliding Hip Michael Weaver, MD, is an Orthopaedic Trauma Surgeon at Brigham &
Screw): Not all fractures do better when treated with a cepha- Women’s Hospital, Boston, MA.
lomedullary nail. Subtrochanteric, reverse obliquity and unsta-
References
ble (3- & 4-part) patterns tend to do better with intramedullary
1. Braithwaite RS, Col NF, Wong JB. Estimating Hip Fracture Morbidity, Mor-
fixation. I prefer to use a sliding hip screw (DHS) for simple 2- tality and Costs. J Amer Geriatrics Soc 2003; 51(3):364-370.
part intertrochanteric hip fractures as this implant spares the ab- 2. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM.
ductors. The DHS is also substantially less expensive. Outcomes for Older Patients With Hip Fractures: The Impact of Orthopedic
Other fixation options: Occasionally, previous surgery or pre- and Geriatric Medicine Co-care. J Ortho Trauma 2006; 20(3):172-180.
existing deformity precludes standard fixation of hip fractures. It 3. Konstantin V, Grigoryan MS, Javedan H, Rudolph SM. Ortho-Geriatric Mod-
els and Optimal Outcomes: A Systematic Review and Meta-Analysis. J
is thus useful to be familiar with techniques such as the use of
Trauma (submitted).
blade plates and proximal femoral locking plates (Figure 2).
4. Weaver MJ, Miller M, Vrahas MS. The Orthopaedic Implications of Disphos-
AchesAndJoints.org/Trauma phonate Therapy. J Am Acad Ortho Surg 2010; 18:367-374.
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Trauma Rounds, Volume 4, Winter 2013